In H.0.F. Veiel and U. Baumann (Eds.) (1992). The meaning and measurement of social support. New York: Hemisphere Press. 8 Stress, Social Support, and Disorder Sheldon Cohen Camegie Mellon University, Pennsylvania, USA ‘The concepts of social suppor and stress have been closely tied in both theoret- cal and empirical work on the influence of support on health and well-being (Cas: sell, 1976; Cobb, 1976; Cohen & Syme, 1985; House, 1981). Social supports are thought to contribute to the generation of stressful events, the avoidance of stress- ful events, the appraisal of events, and the ability to cope with events and their consequences. Conversely, stressful events and coping responses are thought to ‘afuence the stability of social networks as well as the availability and mainte- tance of social supports. This chapter provides an overview of the interrelations berween stress and social support with implications for health outcomes SUPPORT CONCEPTS ‘There is lite agreement among members ofthe scientific community in regard 128 precise definition of social support (Cohen & Syme, 1985; Shumaker & srownell, 1984; Wilcox & Vernberg, 1985). Moreover, existing studies apply the ‘erm to a broad range of social networks and functions that they provide (House, 981; Tumer, 1983). Rather than attempt an all-encompassing definition, | pro- ose broad categorical classifications ofthe concepts commonly included under the Secial support rubric. Three classes of support concepts (measures) are proposed: social networks, perceived social suppor, and supportive bebaviors. Social networks refer to the structure of social relationships—the existence, ‘uantt, and type of relationships. Perceived social support refers to the function of social relationships—the perception that social relationships will (if necessary) ove resources such as emotional support or information. Finally, supportive behaviors refer to the mobilization and receipt of behaviors intended t0 aid persons in the face of stressful events, THE TRANSACTIONAL MODEL OF STRESS Figure I depicts the major concepts and mechanisms involved in relations be- {ween stress and support in the prediction of disorder. Disorder is broadly used bere to refer to both psychological and physiological symptoms and disease states For the sake of simplicity and brevity, the figure does not include all possible relations between concepts. The core of Figure 1 is the transactional model of stress and disorder (e-g., Lazanis & Folkman, 1984). (The “core” concepts key to the transactional model10 S.COMN SECU] (Srmessral) (sms { Imerwomad| |"Evens | |APPRaIsaL eo Seer} | ot |] seme Disonpex oe bese Tet om Figure 1 Mor conceps and mechanisms involved in relations between zest and vocal suppor + the prelcion of disorder are in the octagonal boxes.) In short, potentially stressful events are appraised 2s either stressful or benign in the context of an individual's own values, besiefs, experiences, and coping resources. The appraisal of events as stressful can cesult in a range of psychological and physiological changes that put a person at risk for isorder. ‘As apparent from the figure, there are @ number of objective event characteris: tics that contribute to whether Or not stressful events result in stress and dis ler. ‘These include severity, context in which they occur, duration, and timing f° events in relation to the life course. There is also evidence that specific types .i events are risk factors for specific disorders. For exemple, depressive affect xs clinical depression appear to be triggered by interpersonal events (e.g., Bolgei, DeLongis, Kessler, & Schilling, 1989, Brown & Harris, 1989). Finally, the accu ‘mulation of multiple events may, within a specific category (e.g., interperscaa! events, economic events) of across categories, create a greater risk than single events, ‘As noted earlier, stress appraisal occurs in the context of a person's values, beliefs, experiences, and coping resources. Appraisal represents the meaning of ‘events to the individval—specifically, the extent to which the demands of situations are greater than the ability to cope. In the current discussion, we use the term stress to refer to both the psycho cal and physiological effects of stress appraisal. Psychological effects of appraisal that are implicated in disorder include increased negative affect, lowered self-‘STRESS, SOCIAL SUPPORT, AND DISORDER m esteem, and lowered feelings of control. Physiological changes in response to saress appraisal are presumed to be mediated by these changes in affect, esteem, and control. Physiological stress effects implicated in physical disorder include changes in cardiovascular response, such as increased heart rate and blood pres- sure; secretion (into the bloodstream) of a range of hormones, including catechol- amines, CRF, ACTH, cortisol, and growth hormone; and changes in immune function (Rabin, Cohen, Ganguli, Lysle, & Cunnick, 1989). ‘The remainder of Figure 1 depicts the interrelations of social networks, per- ceived support, and support behaviors within the transactional model. This in- cludes their effects on the components ofthe core model and their effects on one another. The figure is intended as an organizational tool, not as the representation of a formal model. The following discussion reviews what is known about the interrelations represented in the figure and speculates about relations when date are insufficient. The reader may want to refer to Figure 1 as an organizational guide while reading this discussion. SOCIAL NETWORKS, STRESS, AND DISORDER Social networks can influence both the occurrence and appraisal of stressful life events. Event occurrence can be affected by social norms. For example, prohibi- ‘control, and abortion can operate to ereate and/or maintain ly, norms supporting the use of birth con- es could prevent unwanted pregnancies and sexually ‘wansmited diseases (e.g, Fisher, 1988). Likewise, network availability of appro- priate information can help people avoid certain stressful life events (€-g., un- ‘wanted pregnancies), whereas inappropriate information may facilitate their oceur- rence Network membership itself provides the possibility for stressful interpersonal events, such as social conflicts and losses, that are less likely for more isolated persons. However, networks also generate events, such as religious and ethnic ceremonies, whose occurrences mark different stages of the life cycle. These events contribute to the development of senses of self, predictabili that are essential for maintenance of psychological well-being. The aonoccurrence of these normative events among relatively isolated persons may also be stressful inerpersonal events (Schulz & Rau, 1985; Rabkin & Strvening, 1976). Inerper- tonal events (occurrence or nonoccurrence) may put people at greater risk for disorder than nonsocial events, Interpersonal events play primary roles as risk factors in psychological distress (¢.g., Bolger et al., 1989; Monroe & Simons, in press; Fiore, Becker, & Coppel, 1983; Pagel, Erdly, & Becker, 1987; Thoits, 1985), clinical depression (e.g., Brown & Harris, 1989; Paykel, 1974), and physi- ‘al illness (.g., Graham, Douglas, & Ryan, 1986; Meyer & Haggerty, 1962). Social networks can also influence the appraisal of stressful events (see path from social networks to stress appraisal in Figure 1). Social norms and information vetworks provide a social context in which events are appraised (Brown & Harris, 1978, 1989; Lazarus & Folkman, 1984; Monroe & Depue, 1991). For example, unwanted pregnancies, divorces, and abortions are considerably more stressful ‘hen network norms forbid or stigmatize them than when norms are accepting or even facilitating, Social networks also directly influence perceptions of support (Gee path from social networks to perceived social support in Figure 1). Support